Mass. Physicians Call On State To Address ER 'Boarding' Of Patients Awaiting Admission

UPDATE: On Feb. 3, the state's Executive Office of Health and Human Services (EOHHS) responded to WBUR's questions with a statement saying the coronavirus pandemic has led to more people seeking emergency and inpatient psychiatric care. It said EOHHS "is acutely aware of the increases in wait times for treatment, and is focused on expanding licensed inpatient psychiatric treatment capacity and reducing emergency room wait times."

The state said in its statement that it is working with hospitals and providers to add more than 200 psychiatric beds starting this spring.

According to an EOHHS spokesperson, ED boarding for psychiatric beds has increased since June by 200-400% over the previous year. That is based on data from the state Department of Mental Health, which the spokesperson says tracks ED boarding regularly.

ORIGINAL STORY:

It happened on one of Dr.  Jesse Rideout's recent shifts in the emergency department at Tufts Medical Center, just as it's happened so many times before at hospitals across Massachusetts.

A young woman — a college student — came to the ER in mental health crisis. She had just returned to school from holiday break and was struggling with some newfound pressures related to the pandemic, Rideout said.

"She did have underlying depression," he said. "But ... lack of sleep, lack of eating and thoughts of harming herself sort of brought her in in a crisis mode."

But the hospital couldn't get her what she needed after her initial assessment: a bed in an inpatient psychiatric unit.

"It was several days waiting for a bed to open up," Rideout recalled.

For many people in the grip of a mental health crisis, the fastest way to get help is to go to a hospital emergency room. But according to data collected by the Massachusetts College of Emergency Physicians (MACEP) — of which Rideout is president — when those patients need to be admitted to an inpatient psychiatric unit, the process can be painfully slow; and wait times are getting worse.

That means patients often must stay in the ER for many hours — or even days — before they're admitted or are transferred to another hospital that can admit them. Doctors refer to it as emergency department, or ED, "boarding."

Data MACEP provided to WBUR — from its recent biannual point-in-time survey, to which 70% of Massachusetts hospitals responded — show that on Jan. 18, there were 244 people boarding in hospital EDs across the state while awaiting inpatient beds for behavioral health care.

The data show the patients had boarded for an average of 53 hours per person. For pediatric behavioral health patients alone, the average wait was even longer: 59 hours. And the total number of hours psychiatric patients had boarded in emergency departments was 10,527 -- the highest total MACEP had ever recorded, according to Rideout.

The problem of ED boarding is long-standing and happens at community hospitals and large academic medical centers, he told WBUR's All Things Considered host Lisa Mullins.

"Looking over the past 10 years of data that we've collected, it is fairly demoralizing to see — despite all of our efforts, despite the fact that it's a well-known problem, that things are not getting better," Rideout said. "In fact, the trends are definitely getting worse."

In the pandemic, Rideout said, hospitals have even fewer available behavioral health beds because psych units have to reserve a small percentage of beds for isolation in case any patients test positive for the coronavirus.

And, he added, increased demand because of mental health struggles brought on or intensified by the pandemic is putting extra strain on the system.

"We see a lot of patients that, you know, are having challenges, understandably, coping with the stress of a pandemic," he said. "We're seeing increased depression — both in adults and significant amounts in children — increased anxiety, increased use of substance[s], exacerbating underlying psychiatric illnesses."

Some patients who are boarding — awaiting inpatient beds — are moved into hallways because ED rooms they were in are needed by other patients, Rideout pointed out.

"You feel sort of helpless not being able to initiate the group therapy and then the various psychiatric treatments that are necessary," he said. "And, you know, each of our shifts, as we sort of move from one doctor to the next to the next ... we're essentially saying the same thing: 'This patient continues to wait for a bed.' "

The MACEP data shows that on Jan. 18, on average, 25% of ED beds at any given hospital were filled by patients who were set to be admitted to inpatient psychiatric units but had to wait for beds. That's consistent with what was found last January. But it represents a notable increase from the several years prior.

There was also a sizable increase in patients boarding in emergency rooms while awaiting inpatient admission for physical medical conditions, but the numbers are much lower than for psychiatric boarding. On Jan. 18, hospitals reported there were 147 such medical-surgical patients boarding in ERs. That's down slightly from January 2020, but higher than the previous five years. On the same date five years earlier, there were 57 people boarding in EDs for admission to medical beds.

Cumbersome insurance authorization requirements for psychiatric hospitalizations further tie up the process for admitting patients, leading to higher levels of ED boarding among behavioral health patients, Rideout explained.

In a recent letter to Massachusetts Secretary of Health and Human Services Marylou Sudders, the emergency physicians' organization requested that the state Department of Public Health start tracking and publicly reporting ED boarding data across Massachusetts on a daily basis.

"I think COVID-19 has taught us that Massachusetts is a leader when it comes to reporting the daily updates of COVID-19 and hospitalization. And Gov. [Charlie] Baker has been a leader at using the data to drive decisions and to assess progress," Rideout said. "It would sort of force us to solve this problem."

The Executive Office of Health and Human Services has not responded to WBUR's questions regarding ED boarding and whether the state has considered tracking it more closely.

Rideout stressed that despite delays patients might face getting admitted to a hospital, if they are in mental health crisis they should still go to an emergency room for medical care and for their safety.

Resources: If you're in mental health crisis, you can reach the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) and the Samaritans Statewide Hotline (call or text) at 1-877-870-HOPE (4673). Call2Talk can be accessed by calling Massachusetts 211 or 508-532-2255 (or text c2t to 741741).